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General Data Name: Y.F. Age & Gender: 67/Female Civil Status: Widow Occupation: Housewife Chief Complaint: Left neck pain.

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Presentation on theme: "General Data Name: Y.F. Age & Gender: 67/Female Civil Status: Widow Occupation: Housewife Chief Complaint: Left neck pain."— Presentation transcript:

1 General Data Name: Y.F. Age & Gender: 67/Female Civil Status: Widow Occupation: Housewife Chief Complaint: Left neck pain

2 History of Present Illness Localized left neck pain, graded 3/10 Characterized as stiffness, constant and non- progressive Precipitated on lateral flexion of the neck to the left and right Slightly relieved by application of Salonpas ointment and massage No weakness, swelling, numbness and tingling No associated event prior to said symptom No limitation with ADL Slight limitation in doing household chores June 30, 2010

3 History of Present Illness Persistence of symptoms prompted consult at UST OPD Medicine – Cervical spine Xray (AP, Lateral view) was requested – Unrecalled medication prescribed – Referred to Rehabilitation Medicine OPD 1 day PTA CONSULT

4 Cervical Spine Radiograph Alignment is satisfactory Vertebral height is preserved Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

5 Cervical Spine Radiograph Impression: Alignment is satisfactory Vertebral height is preserved

6 Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

7 Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

8 Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

9 Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

10 Review of Systems (-) wt loss, anorexia, weakness, fatigue, insomnia (-) itchiness, pigmentation, rash, active dermatoses (-) blurring of vision, redness, itchiness, Iacrimation (-) deafness, tinnitus, aural discharge (-) anosmia, epistaxis, sinusitis, nasal discharge (-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion (-) breast masses, discharge, trauma (-) dyspnea, cough, hemoptysis, (-) easy fatigability, chest pain, nocturnal dyspnea, palpitation, syncope, edema (-) phlebitis, varicosities, claudication (-) dyshpagia, nausea, vomiting, retching, hematemesis, melena, hematochezia, belching, indigestion, diarrhea, constipation (-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia, urethral (-) joint stiffness, joint pain, muscle pain, cramps (-) heat-cold intolerance, polydipsia, polyphagia, polyuria (-) headache, seizures, anxiety, depression, IPR difficulties

11 Past Medical History Previous Surgery/Hospitalization – none Major Adult Illnesses - Rheumatoid Arthritis (2000), Diclofenac mg taken for 5 years Immunizations: unrecalled Medications/supplements: none Allergies: none

12 Family History (+) Arthritis: sister (-) HPN, DM, Heart disease, Asthma, PTB, Cancer, Thyroid disorder

13 Personal and Social History Mixed diet (vegetables, fish & fruits) Non smoker, Non alcohol beverage drinker Denies illicit drug use Housewife, lives with her 2 sons Does all the household chores Does stretching exercise everyday Sleeps at around 8 hours/day


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